Chapters 17, 18, 19 Med/Surg
After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements?
"I'll be sleepy but able to respond to your questions." Explanation: With moderate sedation, the patient can maintain a patent airway (i.e., doesn't need a tube to help breathing), retain protective airway reflexes, and respond to verbal and physical stimuli. The patient is not unconscious with moderate sedation. Local anesthesia involves anesthetizing or numbing the area of the surgery.
A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate?
"You will be lying on your side with your knees to your chest." Explanation: For the lumbar puncture procedure, the client usually lies on the side in a knees-to-chest position. A position flat on the table, face down does not open the vertebral spaces to allow access for the lumbar puncture. Having the client lie on their back does not allow access to the surgical site.
The nurse is assisting with positioning the patient on the operating table. The nurse understands that the most commonly used position is which of the following?
Dorsal recumbent Explanation: The usual position for surgery is the dorsal recumbent position. The Trendelenburg position is used for surgery on the lower abdomen and pelvis. The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures. The Sims or lateral position is used for renal surgery.
The nurse is educating new employees about wearing masks in the operating room. What information should the nurse provide? Select all that apply.
Masks should cover the nose and mouth completely. You must change masks between treating clients. Masks should fit tightly. Explanation: Masks are changed between clients. Regardless of time, masks should not be worn outside the surgical department. Masks should fit tightly and cover the nose and the mouth completely. The mask must be either on or off; it must not be allowed to hang around the neck. Masks must be worn at all times in the restricted zone. The semi-restricted zone requires scrubs and cap.
What is an example of an intravenous anesthetic that is a hypnotic and produces excellent amnesia?
Midazolam Explanation: Midazolam (Versed), an excellent hypnotic, is often used as an adjunct to induction.
A patient who has received general anesthesia has reached stage II. Which of the following would the nurse expect the patient to exhibit?
Pupillary dilation and rapid pulse Explanation: During stage II, or the excitement stage, of general anesthesia, the pupils dilate and the pulse rate is rapid. During stage I, warmth, dizziness, and a feeling of detachment may be experienced. During stage III, the patient is unconscious, respirations are regular, and the pulse rate and volume are normal. During stage IV, respirations become shallow, the pulse is weak and thready, the pupils become widely dilated, and cyanosis develops.
A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider?
The client has an absence of bowel sounds. Explanation: A nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and breathe deep. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to monitored and brought to the physician's attention when assessing the client. p. 472
The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?
The client reports a small bowel movement. Explanation: A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met. All of the other options are components of meeting the outcome of functioning. p. 472
The nurse cares for a client who is three hours post op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms?
Wound approximation Explanation: Hiccups are produced by intermittent spasms of the diaphragm, secondary to irritation of the phrenic nerve. Hiccups may be caused by surgery and are usually not problematic. However, persistent or forceful spasms may lead to wound dehiscence, or wound separation at the surgical incision. The other answer choices are things the nurse will monitor; however, the approximation of wound edges will be monitored more closely. p. 471
A novice nurse provides aftercare instructions to a client who has just had sutures removed. Which statement by the novice nurse requires the nurse preceptor to clarify?
"If the wound edges are red or raised, you should call your doctor." Explanation: Wound edges that are slightly red or raised are normal and do not require the client to report these findings to the health care provider. All other statements are true. p. 471
Using the PACU room scoring guide, a nurse would give a patient an admission cardiovascular score of 2 if the patient's blood pressure is what percentage of his or her preanesthetic level?
20% Explanation: The patient would receive a cardiovascular/circulation score of 2 if the blood pressure is 20% of the preanesthetic level. p. 461
What measurement should the nurse report to the physician in the immediate postoperative period?
A systolic blood pressure lower than 90 mm Hg Explanation: A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal. p. 461
To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care?
Assist with oral fluid intake. Explanation: Dehydration, immobility, and pressure on leg veins promote venous stasis, which can lead to thromboembolism. p. 473
The nurse recognizes that the client most at risk for mortality associated with surgery is the:
Client with chronic alcoholism Explanation: The client with chronic alcoholism who experiences alcohol withdrawal symptoms is at significant risk for mortality, which can be attributed to cardiac dysrhythmias, cardiomyopathy, and bleeding tendencies.
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia?
Dantrolene sodium Explanation: Anesthesia and surgery should be postponed. However, if end-tidal carbon dioxide (CO2) monitoring and dantrolene sodium (Dantrium) are available and the anesthesiologist is experienced in managing malignant hyperthermia, the surgery may continue using a different anesthetic agent.
During the first 24 hours after surgery, how often will the nurse evaluate the client's temperature?
Every 4 hours Explanation: The pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours. Thereafter, they are measured less frequently if they remain stable. The temperature is monitored every 4 hours for the first 24 hours. p. 463
The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of:
Hypoxemia and hypercapnia. Explanation: The primary objective in the immediate postoperative period is to maintain pulmonary ventilation and thus prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. Besides checking the health care provider's orders for and administering supplemental oxygen, the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds. p. 457
As a circulating nurse, what task are you solely responsible for?
Keeping records. Explanation: The circulating nurse wears OR attire but not a sterile gown. Responsibilities include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, receiving specimens for laboratory examination, and coordinating activities of other personnel, such as the pathologist and radiology technician. It is the responsibility of the scrub nurse to hand instruments to the surgeon and count sponges and needles. It is the responsibility of the surgeon to estimate blood loss.
Which of the following positions would the nurse expect the client to be positioned on the operating table for renal surgery?
Lateral (Sims) position Explanation: The client undergoing renal surgery will be placed in the Lateral, also known as the Sims position.
An example of an intravenous anesthetic that is a hypnotic and produces excellent amnesia is:
Midazolam Explanation: Midazolam, an excellent hypnotic, is often used as an adjunct to induction. Refer to Table 5-6 in the text.
A client is administered succinylcholine and propofol for induction of anesthesia. One hour after administration, the client demonstrates muscle rigidity with a heart rate of 180. What should the nurse do first?
Notify the surgical team. Explanation: Tachycardia and muscle rigidity are often the earliest signs of malignant hyperthermia. Early recognition of malignant hyperthermia increases survival. The nurse would document the findings, and administer dantrolene sodium, obtain cooling blankets as part of the treatment for malignant hyperthermia, but the nurse would need to ensure the surgical team is aware of the findings first.
A patient is scheduled for a reduction mammoplasty. What classification of surgery does the nurse understand that this is?
Optional Explanation: Cosmetic surgery, including reduction mammoplasties, is optional, as the decision to have the surgery rests with the patient.
The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order?
chlorpromazine Explanation: Chlorpromazine (Thorazine) is used to treat intractable hiccups. p. 471
When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as
clean contaminated. Explanation: Clean contaminated cases are those with a potential, limited source for infection, the exposure to which can largely be controlled. Clean cases are those with no apparent source of potential infection. Contaminated cases are those that contain an open and obvious source of potential infection. A traumatic wound with foreign bodies, fecal contamination, or purulent drainage would be considered dirty. Table 19-5, p. 474
The nurse recognizes that a traumatic wound with fecal contamination would be classified as
dirty. Explanation: An example of a dirty wound includes a traumatic wound with delayed repair, devitalized tissue, foreign bodies, or fecal contamination. A clean wound occurs at a nontraumatic site or at an uninfected site. Examples of clean contaminated wounds include appendectomy or a minor break in aseptic technique. An example of a contaminated wound is gross spillage from the gastrointestinal tract. Table 19-5, p. 474
A patient with renal failure is scheduled for a surgical procedure. When would surgery be contraindicated for this patient due to laboratory results?
A blood urea nitrogen level of 42 mg/dL Explanation: The kidneys are involved in excreting anesthetic medications and their metabolites; therefore, surgery is contraindicated if a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems (see Chapter 54). A blood urea nitrogen level of 42 mg/dL (significantly elevated) is an indicator of renal failure. The other levels are normal.
A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease (COPD). The nurse bases her next action on the principle that:
it may be necessary to raise the head of this client's bed. Explanation: The nurse should consider positioning when caring for a client who has COPD and difficulty breathing. Elevating the head of the bed assists these clients in breathing. There's no indication that it's necessary to intubate the client. A Foley catheter isn't indicated. Prophylactic I.V. antibiotics aren't administered with moderate sedation.
When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation, although the patient's breathing appears normal, the nurse identifies that the patient may be suffering from which type of hypoxemia?
Subacute Explanation: Supplemental oxygen may be indicated for subacute hypoxemia. Hypoxic hypoxemia results from inadequate breathing. Episodic hypoxemia develops suddenly, and the client may be at risk for myocardial ischemia, cerebral dysfunction, and cardiac arrest. Anemic hypoxemia results from blood loss during surgery. p. 465
Which nursing diagnosis should the nurse plan to address first in the client upon arrival in the intraoperative setting?
Anxiety related to ineffective coping with surgical concerns Explanation: Putting the client at ease helps the client prepare for the surgical experience by promoting psychological comfort of the client and giving the client a sense of control.
A client develops a hemorrhage one hour post surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred:
within the first few hours, and has darkly colored blood that flows quickly. Explanation: An intermediary hemorrhage appears within the first few hours following surgery. Darkly colored blood that flows out quickly indicates a venous hemorrhage. A hemorrhage that occurs during surgery is classified as a primary hemorrhage. A bright red color indicates that a hemorrhage's source is an artery. Secondary hemorrhages occur when sutures slip or drainage tubes dislodge insecure vessels. p. 459
The nurse is working in the preoperative area with a client going to surgery for a cholecystectomy. The client has histamine2-receptor antagonists ordered preoperatively. The client asks the nurse why these medications are needed. What would be the nurse's best answer?
"These medications decrease gastric acidity and volume." Explanation: The anesthesiologist frequently orders preoperative medications. Common preoperative medications include the following: anticholinergics, which decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation; anti anxiety drugs, which reduce preoperative anxiety, slow motor activity, and promote induction of anesthesia; histamine2-receptor antagonists, which decrease gastric acidity and volume; narcotics, which decrease the amount of anesthesia needed, help reduce anxiety and pain, and promote sleep; sedatives, which promote sleep, decrease anxiety, and reduce the amount of anesthesia needed; and tranquilizers, which reduce nausea, prevent emesis, and enhance preoperative sedation.
A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate?
Continue with frequent client assessments. Explanation: An immediate postoperative client may be transferred to the PACU with a hard, plastic oral airway in place. The airway should not be removed until the client shows signs of gagging or choking. The neurological status is appropriate for a client who received general anesthesia, and the nurse should continue with frequent client assessments. . None of the information provided requires the client to have vital signs measured more frequently than the standard 15 minutes. p. 458
What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound?
Count the sponges. Explanation: Standards call for the scrub nurse and the circulating nurse to count the sponges at the beginning of the surgery, when the surgical wound is being sutured, and when the skin is being sutured. Tissue specimens should be labeled when obtained. The sutures should be ready before the surgeon needs them. Although the scrub nurse does hand equipment to the surgeon, the sponge count is a higher priority action.
When practicing perioperative care, the nurse monitors clients for what symptoms that are indicative of malignant hyperthermia? Select all that apply.
Cyanosis Muscle rigidity Diaphoresis Irregular heart rate Explanation: Symptoms of malignant hyperthermia include tachycardia, tachypnea, cyanosis, fever, muscle rigidity, diaphoresis, mottled skin, hypotension, irregular heart rate, decreased urine output, and cardiac arrest.
Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis?
Decreased cardiac output Explanation: Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion. p. 458
A postoperative client is being discharged home after minor surgery. The PACU nurse is reviewing discharge instructions with the client and the client's spouse. What actions by the nurse are appropriate? Select all that apply.
Educate on activity limitations. Discuss wound care. Have the spouse review when to notify the physician. Provide information on health promotion topics. Explanation: The nurse should provide education on activity limitations and wound care, and should review complications that require notification to the physician. The nurse should also provide information regarding health promotion topics, such as weight management and smoking cessation. The client should not make any major decisions or sign any legal forms because of the effects of anesthesia. Chart 19-3, p. 463
A medical student scheduled to observe surgery enters the unrestricted surgical zone wearing jeans, a t-shirt, and tennis shoes. What is the best action by the nurse?
Educate the medical student on required attire for each surgical zone. Explanation: It would be best to educate the medical student on the required attire for each surgical zone. Because the student will be observing a surgery, he or she will need to dress appropriately in each zone to decrease the risk of introducing pathogens. The unrestricted zone allows for street clothes; therefore, the student does not need to be removed. If no action is taken by the nurse, the student could enter the semi-restricted or restricted zone without appropriate attire. Providing a cap and mask does not address the need to change out of the street clothes to observe the surgery.
A client has been administered ketamine for moderate sedation. What is the priority nursing intervention?
Frequently monitoring vital signs Explanation: Vital signs must be monitored frequently to assess for respiratory depression and to enable quick intervention. Oxygen may need to be administered if respiratory depression occurs; therefore, monitoring vital signs is a higher priority nursing intervention. Providing a dark quiet room is appropriate after the procedure is completed and the client is recovering. Hallucinations may occur as a side effect of the medication.
The operating nurse is caring for a patient who is receiving general anesthesia. Organize the nursing interventions in chronological order of the stages of general anesthesia, beginning with Stage I (1) and ending with Stage IV (4).
Keep discussions about the client to a minimum. Avoid auditory and physical stimuli. Place client into operative position. Prepare for and assist in treatment of cardiac and/or respiratory arrest. Explanation: In Stage I, the client is still conscious and aware of the environment. Therefore, discussions about the client should be kept to a minimum. Stage II is an excitement stage, whereby the client may present with varying behaviors and is susceptible to external stimuli. The nurse should avoid auditory and physical stimuli to facilitate smooth induction of the anesthesia. During Stage III, the client is unconscious and placed into the operative position. Stage IV is characterized by medullary depression and is a life-threatening situation. The nurse prepared for and assists in treatment of cardiac and/or respiratory arrest.
What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site?
Obtain the attention of all members of the surgical team. Explanation: The second verification of the surgical procedure and surgical site should be done at one time and include all members of the surgical team. The marked surgical site is confirmed with all members of the surgical team, not just the surgeon or client. Complications, allergies, and anticipated problems are also discussed among the entire surgical team.
An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults?
Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients. Explanation: The underlying principle that guides preoperative assessment, surgical care, and postoperative care is that elderly clients have less physiologic reserve (the ability of an organ to return to normal after a disturbance in its equilibrium) than younger clients. The hazards of surgery for the elderly are proportional to the number and severity of coexisting health problems and the nature and duration of the operative procedure. Respiratory and cardiac complications are the leading causes of postoperative morbidity and mortality in older adults.
Unless contraindicated, how should the nurse position an unconscious patient?
On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration Explanation: The head of the bed is elevated 15 to 30 degrees unless contraindicated, and the patient is closely monitored to maintain the airway as well as to minimize the risk of aspiration. If vomiting occurs, the patient is turned to the side to prevent aspiration and the vomitus is collected in the emesis basin. p. 457
The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next?
Outline the drainage with a pen and record the date and time next to the drainage. Explanation: Areas of drainage on the dressing should be outlined with a pen, and the date and time should be recorded next to the drainage. Blood drainage from the incision is a normal expected finding in the immediate postoperative period; however, excessive amounts should be reported to the surgeon. p. 469
A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.
Position the client in Fowlers position. Don sterile gloves. Lubricate the sterile suction catheter. Insert suction catheter into the lumen of the tube. Apply intermittent suction while withdrawing the catheter. Explanation: Suctioning a tracheostomy is a sterile procedure. The nurse should first position the client in Fowler's position then don sterile gloves. Next, the nurse will lubricate the sterile suction catheter and insert the catheter into the lumen of the tube. Finally, the nurse will apply intermittent suction while withdrawing the catheter. p. 515
As a nurse working in an ambulatory surgery center, you are admitting a client who is going to have a biopsy of a skin lesion. What is an important part of the preoperative process?
Review preoperative instructions On admission, the nurse reviews preoperative instructions, such as diet restrictions and skin preparations, to ensure the client has followed them. The preoperative nurse does not give postoperative instructions; teach dressing changes or give instructions to caregivers.
A nurse is caring for a client who is scheduled to have a thoracotomy. When planning care for this client, what mobility teaching will the nurse include in the plan of care?
Shoulder and upper arm range-of-motion exercises Explanation: Because large shoulder girdle muscles are transected during a thoracotomy, the arm and shoulder needs mobilization with range-of-motion exercises. Lower back and rib cage exercises are not a standard therapy for those recovering from a thoracotomy. The use of a cane is not a standard assistive device necessary after a thoracotomy.
The nurse should determine that a client is coughing effectively after surgery if the nurse observes which of the following activities?
The client takes a deep abdominal breath and then "huff" or "hack" coughs three or four times. Explanation: Taking a deep abdominal breath and then "huff" coughing is the most effective manner of coughing. This technique helps facilitate removal of secretions and conserves energy for the client. The client should breathe slowly but not hold her breath. Short, panting breaths and then coughing from the throat do not promote expectoration of sputum from the lungs. Coughing forcefully can cause alveoli to collapse; "huff" coughing prevents this.
A client is being prepared for a same-day surgical procedure and is discussing with the nurse what potential ramifications this type of surgery has. Which of the following would the nurse correctly identify? Select all that apply.
The client will leave the hospital sooner than in the past. Need for teaching is increased. The client must be prepared to take on more self-care than he or she may have done in the past. Explanation: The increasing use of ambulatory, same-day, or short-stay surgery, means that clients leave the hospital sooner, which increases the need for teaching, discharge planning, preparation for self-care, and referral for home care and rehabilitation services.
A 72-year-old woman will be having total hip arthroplasty this morning to repair a fracture that she suffered in a recent fall. What patient teaching should the nurse prioritize during the preoperative phase of this patient's care?
The positioning that the patient will be asked to adopt postoperatively Explanation: Some patients require instruction about special positions that are required after surgery (in this case, abduction of lower extremities). Reviewing the process before surgery is helpful, because the patient may be too uncomfortable or drowsy after surgery to absorb new information. This information is vital to the patient's safety, pain levels, and course of recovery. As such, it would likely be prioritized over teaching about nutrition or IV therapy. It is not likely necessary for the nurse to provide an overview of the relationship between aging and recovery.
A postoperative client returns to a surgical nursing unit. The nurse assesses the client and notes tachycardia and muscle rigidity. What is the most important nursing action?
administering supplemental oxygen Explanation: Recognizing symptoms early and discontinuing anesthesia promptly are imperative. The goals of treatment are to decrease metabolism, reverse metabolic and respiratory acidosis, correct dysrhythmias, decrease body temperature, provide oxygen and nutrition to tissues, and correct electrolyte imbalance. The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Notifying the health care provider is important but not the first action of the nurse. The client with malignant hyperthermia needs to have temperature monitored, but this is not the first action. Inserting a urinary catheter will not provide oxygen to the client's tissues and reverse complications from the anesthesia.